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State high court sides with the ISMA, Indiana Spine Group on worker’s comp case
e-Reports, Feb. 6, 2012
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You may have time to challenge old under-reimbursed claims, as a result Untitled document

If you believe you have been under-reimbursed on past worker’s compensation claims, you may still have time to pursue them. The ISMA’s amicus curiae (friend of the court) brief helped convince the Indiana Supreme Court to rule against insurer challenges to worker’s compensation reimbursements.

Case background
In 2004, the Indiana Spine Group (ISG) began treating a patient for a work-related injury sustained in 2003. ISG submitted claims and received partial reimbursements in 2004 and 2008 from the worker’s compensation carrier, Pilot Travel.

With an unpaid balance of $21,751, the ISG filed an Application for Adjustment of Claim for Provider’s Fee in 2009 with the Indiana Worker’s Compensation Board. The insurer objected, stating the petition had to be filed within two years of the date when it last paid the employee compensation, even though that timeline was unrelated to treatment, billing or payment dates.

The board twice dismissed ISG’s application as time-barred. ISG appealed, arguing that the worker’s compensation law doesn’t include an applicable statute of limitations.

The ISMA supported ISG’s position, arguing a two-year statute of limitations from the date of injury or the last day for which compensation was paid was unreasonable and absurd. Moreover, the ISMA claimed the carrier’s argument as supported by the board was disingenuous. The appellate courts unanimously agreed with us.

The Indiana Supreme Court justices concurred last November that the carrier’s position could lead to absurd results that would “leave medical service providers little incentive to treat injured workers.” Instead, the court concluded, a catch-all 10-year statute of limitations applied to such claims. Therefore, ISG’s application was timely filed.

“This case is a true testament to the value of fighting the fight. What the insurance carrier was doing was wrong, the Indiana Spine Group challenged them on that, the ISMA provided valuable industry perspective, and we won,” noted Julie Reed, ISMA general counsel. “The ISMA has already received reports that the Supreme Court’s decision is prompting worker’s compensation carriers to pay additional monies to resolve some pending disputes. That’s real success, measured by real money.”

Money for you, too
For claims before July 1, 2011, presumably you have 10 years to file an Application for Adjustment with the Indiana Worker’s Compensation Board. So, it may be possible to challenge payments for services rendered as far back as 2002.

A new law passed last May applies to claims occurring on or after July 1, 2011. After submitting a bill for services on these claims, you may file an Application for Adjustment within two years of receipt of an initial written communication from the employer, employer’s agent or employer’s insurance carrier.

Paid properly?
Current law requires health care providers to be paid an amount not to exceed the 80th percentile of all charges for the same coded procedure within a defined geographic area (first three digits of zip code). A provider’s billed charges are presumed to be correct, so a worker’s compensation carrier seeking to pay less than the full billed amount must prove the provider’s charges exceed the 80th percentile.

However, determining the 80th percentile can be challenging. The primary industry database, Ingenix, is cost-prohibitive. More importantly, government investigations determined Ingenix was flawed. Class action lawsuits by the AMA prompted most major payers to discontinue using it and contribute money to the formation of a new, non-profit, independent database called FAIR Health.

Legislation is pending in Indiana to give better transparency to worker’s compensation reimbursement, including certification of one or more databases, like FAIR Health.

Meanwhile, the ISMA can provide you with referrals to attorneys with expertise in these reimbursement matters.

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